Completing the Employer Sign-up Form is the first step to getting your HSA program up and running! By completing this form, you will gain access to HSA Bank’s employer site, which is designed to help you manage your benefits program. The site allows you to contribute to your employees’ HSAs, manage your list of employees, access education materials, and much more.

Within 2 business days after submitting the below form, a summary of your enrollment and contribution options will be emailed to you. If you have questions, or if you are interested in learning more about our full CDH product suite, contact a Business Relations Representative at (866) 357-5232, Monday through Friday, 7 a.m. to 7 p.m., Central Time.

Please provide us with your complete, legal company name (do not include your “Doing Business As” or operating names). This will help to ensure accurate and timely processing.

* Legal Company Name:

* Federal Tax ID Number:

* Employer Entity:

* Number of Employees in
Company:

* Number of Employees Eligible for Benefits:

* Street Address:

* City:

* State:

* Zip Code:

* P.O. Box:

YesNo

* P.O. Box Address:

* City:

* State:

* Zip Code:

* Phone Number:

-
ext.

Fax Number:

-

* Effective Date of HSA:

/
/

* Effective Date of High-Deductible Health Plan:

/
/

* Open Enrollment - Start and End Dates:

-

Select Primary Contact

The Primary Contact is an employee within your company who will have full administrative privileges in the employer site. These privileges include the ability to add administrative users and assign permissions to administrative users.

* First Name:

* Last Name:

* Email:

* Phone Number:

-
ext.

Fax Number:

-

Set-up Preferences

The Employer Guide provides more information about your set-up preferences.

By completing the fields below, I (we) hereby authorize HSA Bank, a division of Webster Bank, N.A., hereinafter called HSA Bank, to initiate debit entries to my (our) checking account/savings account indicated below at the depository financial institution names below, hereinafter called DEPOSITORY, and to debit the same to such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law.

This authorization is to remain in full force and effect until HSA Bank has received written notification from me (or either of us) of its termination in such time and in such manner as to afford HSA Bank and DEPOSITORY a reasonable opportunity to act on it.

NOTE: ALL WRITTEN DEBIT AUTHORIZATIONS MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE AUTHORIZATION.

* Branch Name:

* Branch Street Address:

* Branch City:

* Branch State:

* Branch Zip:

* Routing Number:

* Account Number:

* Type of Account:

CheckingSavings

* Is your Invoice Contact the same as your Primary Contact?

YesNoIf no, please provide contact information below.

*First Name:

*Last Name:

*Email:

*Phone Number:

-
-
ext.

* Street Address:

* City:

* State:

* Zip:

Referral Tracking Codes

If you were not provided any referral tracking codes, please
leave the below fields blank.

Broker Dealer:

Marketing Code:

Health Plan Code:

Software Vendor:

AIN:

MGA:

SVC:

TPA:

Any referral tracking code information provided to you by HSA Bank for purposes of verifying enrollment and transaction information is provided for this specific purpose. You are responsible for properly safeguarding this information. HSA Bank will not be liable for any unauthorized use or disclosure to the extent allowed by law.